Comprehensive review on Maxillary Osteotomies for Facial Skeletal discrepancies along with associated complications and their management.

1. MAXILLARY OSTEOTOMIES &
SURGICAL COMPLICATIONS
Presented by- Dr. Varun Mittal PG
Maxillofacial Surgery Dept., SRM Dental College,
Chennai, INDIA

2. • HISTORY
• BIOLOGICAL BASIS
• WOUND HEALING
• SURGICAL APPROACHES
• MAXILLARY PROCEDURES
• MAXILLARY DEFORMITIES
• INDICATIONS
• COMPLICATIONS

3. 1859 → von Langenback, nasopharyngeal polyps
1867 → David Cheever, hemimaxillary
downfracture for complete nasal obstruction
1921 → Cohn-Stock, AMO (mainly occlusion)
1927 → Wassmund, Lefort I without PMD
1934 → Axhausen, Complete mobilization 1st time
1942 → Schuchardt, PMD
1950 → Gillies & Harrison, 1st Lefort II osteotomy

4. 1950 → Gillies & Harrison, 1st midface
advancement using Lefort III osteotomy cuts
1965 → Obwegeser, suggested complete
mobilization
1969-75 → Bell, Lefort I downfracture & formed
the BIOLOGICAL BASIS
1971 → Converse et al; 1971 → Kufner et al &
1973 → Henderson & Jackson Lefort II as
classified by Steinhauser in 1980
1985 → Bennet & Wolford; Lefort 1 Step-
osteotomy

5. BIOLOGIC BASIS..
Bell et al; “Wound healing after multisegmental
Lefort I osteotomy and transection of the
descending palatine vessels”, J Oral & Maxillofacial
Surg 1995
• Study examined Le Fort I osteotomy wound healing
after downfracture in 9 rhesus monkeys through
circumvestibular incisions later, killed at 0, 3, 7, 14,
and 28 days after surgery. Revascularization and
bone healing were studied & proposed that the
palatal mucosa or labial-buccal gingiva and mucosa
provide adequate nutrient pedicles for Le Fort I
osteotomies accomplished through a
circumvestibular type incision.

8. • Siebert et al; 1997, “Blood Supply of the Le
Fort I Maxillary Segment: An Anatomic Study”
performed study on 10 fresh cadavers by
injecting standard latex technique.
• Demonstrated interruption of the descending
palatine arteries with preservation of the
ascending palatine branch of the facial artery
and the anterior branch of the ascending
pharyngeal artery within the attached
posterior palatal soft-tissue pedicle in all
specimens following Le Fort I maxillary
osteotomy.

9. Lateral view of right face on a
fresh cadaver with posterior
half of mandible & zygoma
removed. Within the right
temporal and pterygoid fossae,
the internal maxillary artery and
its branches are demonstrated
(large arrow). The facial artery
is seen crossing the mandible
and continuing up toward the
orbit (curved arrow). The
anastomotic network between
branches of the facial artery and
branches of the internal
maxillary artery on the inner
surface of the gingival mucosa

11. • The ascending palatine br. of the
facial artery was 1 to 1.5 mm in
diameter ; entered soft palate by
crossing over the L.V.palatini
muscle.
• Anterior br. of ascending
pharyngeal artery ; 0.8 to 1.2 mm
in dia entered soft palate slightly
more cephalad compared with
ascending palatine by coursing
over T.V. palatini and L.palatini
muscles.
• Both branches entered soft palate
posterior to pterygoid muscles &
rich anastomotic network existed
within the maxilla between the
ascending palatine branch, the
anterior branch of the ascending
pharyngeal artery, and the alveolar
branches of the internal maxillary
artery.

12. • Dale Bloomquist -1995 studied blood flow in
human gingiva & pulp during 1st 24 hrs.
following Lefort 1 osteotomy by laser doppler
flowmetry
• Dodson -1993 measured intraoperative
maxillary gingival blood flow during Lefort I
osteotomy (JOMS; 1993)

13. Healing after osteotomy
• Transient ischemia → Fibrinous clot formation
incorporated with RBC’s & some WBC’s
• 1st week postop - increased periosteal-
endosteal vascular supply reducing osseous &
pulpal ischemia.
• Granulation tissue formation in Space
between bones
• 2 weeks post-op- Tissue matures & numerous
blood vessels develop with early sign of
osteophytic bone fromation

14. • 4 weeks post-op →proliferated endosteal
vessels restore circulation between bone
segments, fibrous callus formed
• 6 weeks post-op →bony bridges connect the
osseous segments
• 12 weeks →maturation of soft & hard tissue
continues upto 12 weeks

15. Syndromes with maxillary deformity
Aperts syndrome
Crouzons syndrome
Pfeifer syndrome
Binders syndrome
Achondroplasia
Cleidocranial dysplasia

16. Mid face osteotomies-
Segmental maxillary osteotomy
• Single tooth osteotomy
• Corticotomy
• Anterior segmental osteotomy :
Wassmund – 1935
Wunderer – 1963
Epker & walford – 1980
• Posterior segmental osteotomy :
Shushardt – 1959
Kufner – 1971
• Horseshoe osteotomy :
Walford and Epker - 1975

17. Total maxillary osteotomy :
• Le Fort 1 osteotomy :
Classic down fracture ( Bell 1969-75 )
SAME
Quadrangular (Keller and Sather – 1990)
• Le Fort 11 osteotomy :
Anterior L F 11 ( converse et al – 1970 )
Pyramidal L F 11 ( Henderson & Jackson - 1973)
Quadrangular L F 11 ( Kufner – 1971)
• Le Fort 111 osteotomy :
Killies 1940’s , Tessier 1950’s
• Mid face osteotomies :
Zygomatic osteotomies
Malar maxillary osteotomy

18. Transverse maxillary deficiency
• Incidence : 8%
• Etiology : congenital, developmental, traumatic,
Iatrogenic
• Diagnosis : clinical and radiographic examination.
dental cross bite
skeletal cross bites
P A cephalogram
frontal tomography
C T scans.
S A M E :

19. Transverse maxillary deficiency
• Treatment :
1. S D E
2. O R M E
3. S A M E
4. S M O
• Selection of the technique depends upon the skeletal
maturity of the patient.
S A M E :

20. Indications of S A M E :
• Skeletal maxillo-mandibular transverse discrepancy
greater than 5mm
• Significant TMD with a narrow maxilla and wide
mandible
• Failed or orthodontic expansion
• Necessity for a large amount more than 7mm of
expansion
• Extremely thin and delicate gingival tissues with
buccal gingival recession
• Significant nasal stenosis
S A M E :

21. Brown (1938); midpalatal split
Technique of S A M E :
• Subtotal Le Fort 1 osteotomy
• Mandibular dentition should be decompensated
• Maxillary expansion appliance – preoperatively
Surgical technique :
 B/L maxillary osteotomy (pyriform rim to PTF)
 Release of nasal septum
 Midline palatal osteotomy
 Lateral nasal wall osteotomy
 B/L release of the pterygoid plates
 Activation of the appliance : 1-1.5 mm
 Soft tissue closure
S A M E :

24. • Maxilla should remain stationary – 5 days
• Palatal expansion should achieve – 4 weeks
• Skeletal retention 6-12 months.
Complications :
• Similar to Le Fort 1
• Inadequate release of the maxilla (dental tipping,
periodontal breakdown, pain, necrosis)
• Problems with expansion device (lack of appliance
expansion, processing error, stripping of screw.
S A M E :

25. Single tooth osteotomy & Corticotomy
Benefits :
reduction in treatment time
lower incidence of dental relapse
Drawbacks :
Injury to adjacent tooth, periodontal compromise,
devitalization of teeth, need for endodontic therapy.
Technique :
Incision – transverse incision on either side of the tooth.
Osteotomy – 3-5mm apical to root apex
separated with fine osteotomies
fixed to the adjacent teeth with interdental wires.
Anterior and posterior maxillary segmental
osteotomies :

27. 1921 – Cohn Stock.
Indications :
• Correction of bimaxillary protrusion
• Marked protrusion of the maxillary teeth
• Anterior open bite
• To retract the anterior teeth when that cannot be
accomplished by conventional orthodontic treatment.
• When orthodontic tooth movement is inadvisable.
• Improvement in appearance.
A M O Techniques :
• Wunderer
• Wassmund
• Cupar
Anterior maxillary osteotomies :

28. Wassmund technique : 1935
• Preserves both buccal & palatal soft tissues.
• Incision : vertical incision – planned extraction
or interdental osteotomy.
Anterior nasal spine incision.
• Osteotomy : buccal horizontal osteotomy
transpalatal osteotomy
repositioning of entire segment.
Wunderer technique : 1963
Similar to wassmund, except the palate
is exposed by a transverse palatal incision with the
margins away from the osteotomy site.
Anterior maxillary osteotomies :

30. Cupar method
Most commonly used
Technique :
A buccal vestibular incision is created, allowing direct
access to the anterior lateral maxillary walls, piriform
aperture, nasal floor and septum.
Advantages :
• Direct access to the nasal structures
• Unhampered access – bone grafting
• Ability to remove bone under direct visualization
• Preservation of blood supply
• Ease of placement of rigid internal fixation.
Anterior maxillary osteotomies

32. Schuchardt in 1959 :
Indications :
• Posterior maxillary alveolar hyperplasia
• Total maxillary hyperplasia
• Distal repositioning
• Spacing in the dentition
• Transverse excess or deficiency
• Posterior open bite.
Surgical technique :
Incision :
Buccal vestibular incision from 3-7
Vertical incision in the region of anterior and posterior
osteotomy sites.
Parasagittal palatal incision.
Posterior maxillary osteotomy :

34. Osteotomy :
• Horizontal osteotomy 5 mm above the root apices.
• Vertical osteotomy through the extraction sites.
• Posterior vertical osteotomy at Pterygomaxillary junction
• Palatal osteotomy – curved osteotome.
• Acrylic splint (6-8 weeks with bone plate fixation)
• Maxillomandibular Fixation.
Posterior maxillary osteotomy

36. • Horseshoe osteotomy
• Histological purpose
 Maxillary alveolar hyperplasia with or with out
anterior open bite deformity
• Transverse maxillary hypoplasia with vertical
component
Combination anterior and posterior maxillary
osteotomy

37. Indications of various procedures-
Lefort I
Deformity in all 3 planes can be corrected.
AP → Setback (Total+AMO)
Advancement (Total)
Vertical → Setup (Total)
Downgraft (Total)
Transverse → Narrowing (Segmental+Total)
Widening (Segmental+ Total)

38. Surgical technique :
1. Positioning of the patient
2. Modified hypotension
3. Infiltration of the soft tissue with a
vasoconstrictor.
4. Mucosal incision : blade / electrocautrey.
5. Subperiosteal dissection : complications -
perforation of the periosteum, exposure of
buccal pad of fat, perforation of the nasal
mucosa.
6. Reference marks : vertical and horizontal
Le Fort 1 osteotomy

39. 5. Anterior buccal osteotomy : using a reciprocating
saw from buttress to the piriform rim. Osteotomy
parallel to the occlusal plane.
6. Posterior buccal osteotomy : extending from
buttress to the tuberosity. + / - 3mm lower than
the anterior osteotomy. Step b/w ant/post
osteotomy. Impacted 3rd molar should be
removed. Connect anterior and posterior
osteotomies.
Le Fort 1 osteotomy

40. Incision through the mucosa, submucosa, facial
musculature, and periosteum

42. Subperiosteal dissection of the
anterior maxilla

43. Submucosal dissection of the nasal cavity. Note the tip
of the periosteal elevators inside
the piriform aperture

45. 9. Place the holes for inter osseous wires :
10. Separation of the tuberosity from the pterygoid
plates :
11. Complete the posterior osteotomy : damage to
the descending palatine artery, palatal mucosa or
contents of the pterygopalatine fossa.
12. Osteotomy of the lateral nasal wall : Resistance
and audible change – palatine bone.
13. Repeat the osteotomies on opposite side :
14. Complete the Subperiosteal dissection of the
nasal spine : ramus retractor, separate the septal
cartilage from the anterior nasal spine.
Le Fort 1 osteotomy

48. 15. Osteotomy of the septal cartilage and vomer :
16. Maxillary down fracture : several techniques :
digital pressure, row’s maxillary disimpaction
forceps, tessier spreader, smith 3 – prong
spreader or turvey maxillary expander. Modified
leverage technique. (JOMS 62 ; 112-114 : 2004).
Failure to effect maxillary down fracture –
redefine the osteotomies. Mobilize the maxilla.
17. Place a maxillary positioning wire : assist the final
mobilization of the maxilla, pull the maxilla
anteriorly for better vision and access to the
posterior area of the maxilla.
Le Fort 1 osteotomy

51. 18. Exposure of the posterior maxilla : helps in
identifying descending palatine neurovascular
bundle, osteotomies for refinement, to examine
the maxillary sinus mucosal lining and to remove
pathological mucosa.
19. Trim the lateral nasal wall :
20. Contouring of the piriform rim :
21. Reverse the hypotensive anesthesia and check for
any hemorrhage.
22. Feed a wire through holes at the buttress.
23. Place a intermaxillary fixation with the teeth in
the planned occlusion.
Le Fort 1 osteotomy

54. 24. Maxillary reposistiong : rotate and check for
reference points. Great care should be taken at
this step. Both the mandibular condyles should be
ideal relationship to the glenoid fossa.
25. Turbencetomy : soft tissue atrophy or
hypertrophy of the bone. Ventral approach or tear
26. Check the position of the nasal antrum :
27. Tightening of the maxillary wire :
28. Placement of the bone plates : 1.5 mm plates.
29. Wound closure : cinch, v-y closure.
30. Apply a pressure dressing :
Le Fort 1 osteotomy

58. Effect of the alar cinch technique of the width of the
alar base. Note the difference after tying the suture.

60. Tip of the finger (or thumb) everts the lip and nasal
base while suture is passed

61. V-Y closure of a lip incision. A skin hook is placed in the midline
and tissue is gathered for approximately 1 cm with suture

62. The remainder of the incision is closed so that the
superior edge is pulled anteriorly

64. Obwegeser
Keller and Sather – 54 patients
Indications :
• Maxillary – zygomatic horizontal deficiency
• Class 111 skeletal malocclusion
• Maxillary vertical excess or deficiency
• Maxillary transverse deficiency
• Maxillary midline shifts.
Surgical procedure :
High level Le Fort 1 that incorporates almost
all anterolateral aspects of maxilla below
infraorbital nerve and parts of body of malar.
Quadrangular Le Fort 1 osteotomy

66. Steinhauser 1980
• Anterior L F 11 Osteotomies
• Pyramidal L F 11 Osteotomies
• Quadrangular L F 11 Osteotomies.
Anterior Le Fort 11 osteotomies :
Indication :
Nasomaxillary hypoplasia
Surgical procedure :
Pyramidal nasomaxillary osteotomies
Premaxillary osteotomy
Le Fort 11 osteotomy

67. Pyramidal Le Fort osteotomy :
Henderson and Jackson 1973
Indications : nasomaxillary hypoplasia
• Involving dentoalveolar segment
• Excluding dentoalveolar segment (binders syndrome)
• Cleft palate patients
• Pan facial problems.
Surgical procedure :
• similar to Le Fort 1
• Oblique Para nasal skin incision
• Infraorbital rim osteotomy
• Medial canthus – osteotomy over nasal bone
• Bone grafts and fixation.
Le Fort 11 osteotomy

69. Indications :
• Similar to quadrangular Le Fort 1 osteotomies.
• Patients with significant maxillary deficiency that
includes the infraorbital rims and zygomas but also
who have normal nasal projection.
• Surgical procedure : diagram…….
Quadrangular Le Fort 11 osteotomy

70. • Sir Harold Gillies – 1942
• Tessier
High level midface osteotomy surgery
Midface anteriorly or inferiorly or both
Indications :
Total midface hypoplasia primarily in anterioposterior and
vertical dimension.
Syndromic patients (aperts, crouzens syndrome)
Timing :
Growth – completed
Earlier operation : dislocation of eyes, corneal exposure,
sever functional or psychological problems
Le Fort 111 osteotomy

71. Surgical procedure :
Incision : Coronal flap
Intra oral incision – Le Fort 1
Osteotomies :
zygomatic arch, F-Z region, inferior orbital
fissure, medial wall of the orbit, bridge of the
nose. Pterygomaxillary dysjunction,
Bone grafts and fixation.
Modifications : Le Fort 1 osteotomy
Le Fort 1111 osteotomy : advancement of frontal
bone and anterior cranial fossa.
Le Fort 111 osteotomy

73. Incision placement for most female patients and males
with no signs or family history of baldness. The incision
is kept approximately 4 cm behind the hairline

75. Malpositioning :
• Accurate models,
• Not to deviate the surgical treatment plan,
• position of the mandibular condyles.
Bleeding :
• Anesthesia -
• Head position -
• Descending palatine artery -
• Packing -
• Embolization -
• Postoperatively -
• Arteriogram -
Complications of Maxillary Osteotomies

76. Perfusion deficiencies :
• Laser Doppler flowmetry
• Ligation of D P A
• Palatal and posterior soft tissue
• HBO
• Removal of fixation and splints
• Necrosis
Periodontal defects :
• Attached gingiva and interdental papilla
• Good hygiene and nutrition
• Periodontist consultation
Complications of Maxillary Osteotomies

77. Devitalized tooth :
• Osteotomies – 5mm
• Endodontic therapy
Nerve injury :
• Anatomy
• Neurosensory changes
• Careful retraction
• Reasses the patient
• Consider re-exploration
Complications of Maxillary Osteotomies

78. Nasolacrimal injuries:
• Epiphora
• Dacryocystorhinostomy
Oronasal and oroantral fistulas :
• Large expansion
• Intact nasal mucosa
• Decongestants, nasal sprays, antibiotics
• Oral hygiene
• Surgical closure.
Complications of Maxillary Osteotomies

79. Nasal septal deviation :
• Pre op evaluation
• Nasolacrimal obstruction
• Septal crest
• Cinch suture
• Post op – treat as early as possible.
Maxillary sinusitis :
• Decongestants,
• Antihistamines
• Antibiotics
• Nasal spray.
Complications of Maxillary Osteotomies

80. Effects of the maxillary vestibular approach if simple
closure is performed :
the nasal tip loses projection, the alar bases widen, and
the upper lip rolls inward

81. Unaesthetic soft tissue changes :
• Informed consent
• Down turned or unsupported oral commissures
• Excessive impaction should be avoided
• Periosteal suturing
• V-Y closure
Unfavorable fracture :
• Osteotomies,
• Ideal splitting.
Complications of Maxillary Osteotomies

82. Non union :
• R I F technique
• Occlusion
Eustachian tube dysfunction :
• Intubation
• Palatal muscles
• Decongestants, nasal sprays, reassure the patient.
A-V Fistula’s :
• Very rare
• Unexpected neurological signs.
Complications of Maxillary Osteotomies

83. • Rowe and Williams – vol 2
• Peterson –Oral & Maxillofacial Surgery
• Fonseca – vol 3
• Ward Booth – vol 1
• Edward Ellis- Surgical Approaches to Facial
Skeleton
• Neelima Malik
• Articles-JOMS & IJOMS
References